Application for Services
Disability Services
Arkansas State University
870-972-3964 TDD 870-972-3458
For Office Use Only ----Verification of Disability:
Date Disability Verified____________________
Verified by Whom (Name and Title)
______________________________________
***Please print this form and return to Disability Services.
Date
Student:
Anticipated semester of enrollment
 Prospective Student
 New Student
 Current Student
 Returning Student
 Other __________________
Last name:
First:
ASU Student ID #:
________E-mail address
Local Address:
Zip:
Birth date:
_________________
City:
State:
Local Phone:
TDD:
Place of Employment:
Work phone:
Employment hours planned per week while enrolled:
Home Address:
City:
Hours working now:
State:
Parents name:
Zip:
Home phone number
In Emergency Notify:
Relationship:
First Semester attended ASU
Phone:
Semester applying for services:
How did you hear about this program?
Rehabilitation Counselor:
Phone:
ASU Counselor:
Academic Advisor
EDUCATION
 Graduated High School High School GPA
Current year in school:
High School:
College:
Junior
 Freshman
Senior
 Sophomore
Hours completed at ASU:
 GED Date:
 Junior
 Senior
 Graduate School
 Not currently in college
Major:
Other colleges attended:
Dates attended:
Hours completed at other schools:
Education Plan:
 Classes only; no certificate or degree
 Four year college degree
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 One to two year certificate program
 Two year college degree
 Graduate or professional study beyond four years
ABOUT YOUR DISABILITY
What is your disability/disabilities and how would you describe each disability
Primary Disability:
Secondary Disability:
Third Disability:
 Deaf
 Deaf
 Deaf
 Hard of Hearing
 Hard of Hearing
 Hard of Hearing
 Blind
 Blind
 Blind
 Low Vision
 Low Vision
 Low Vision
 Learning Disability
 Learning Disability
 Learning Disability
 Psychiatric/Emotional
 Psychiatric/Emotional
 Psychiatric/Emotional
 Speech Impairment
 Speech Impairment
 Speech Impairment
 Mobility Impairment
 Mobility Impairment
 Mobility Impairment
 Substance abuse
 Substance abuse
 Substance abuse
 Other medical
 Other medical
 Other medical
Disability resulted from:
Have you had this disability since birth:  Yes  No If not, what year were you diagnosed for each
disability?______________________________________
State specific disability, how diagnosed, describe problems and symptoms of the condition.
Other medical information (as it pertains to your overall health):
______________________________________________________________________________ _
Specialists/Physicians Name and Phone number:
____
Please check the services that may be applicable to you:
GENERAL SERVICES:
TESTING SERVICES:
CLASSROOM SERVICE:
 Assistance with registration
 Extended time
 Preferential seating
 Priority registration
 Low distracting room
 Recording lectures
 ACT special testing
 Large print tests
 Assistance with Ghostwriter
 Disability Parking
 Use of computer
 Large print handouts
 Golf Cart Transportation
 Interpreter
 Assistive listening device
Program
 Reader for exams
 Assistance in labs
 Route planning &
 Scribe for exams
 Physical setup in classroom
Mobility orientation
 Special equipment needed
 Books in alternate format
 Assistive devices/equipment loan
 Typist, proofreading
 Tutoring ***May require additional fees
 Self-advocacy skills
 Other
SERVICES/TECHNOLOGY/ASSISTIVE DEVICES YOU HAVE USED:
List the services that you used in public school (high school)
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1.
2.
3.
4.
List the classes that you received tutoring in high school or in college
1.
2.
3.
4.
List the services that you used in other colleges and universities
1.
2.
3.
4.
List the different types of assistive devices you have used in the past
1.
2.
3.
4.
List the computer equipment (hardware and software) and assistive devices that you currently have
access to for educational purposes
1.
2.
3.
4.
List computer programs that you have received training
1.
2.
3.
4.
TECHNOLOGY/ASSISTIVE DEVICES YOU WOULD LIKE TO USE:
List any other computer equipment or assistive devices that can increase academic success
1.
2.
3.
4.
Scholarships received
1.
2.
Dollar Amt
Dollar Amt
ASU DISABILITY SERVICES
EMERGENCY PROCEDURES
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WE NEED SPECIFIC INSTRUCTIONS IN WAYS TO ASSIST YOU, THE STUDENT, IN EXITING A
BUILDING IN AN EMERGENCY SITUATION.
PLEASE ANSWER THE FOLLOWING QUESTIONS:
 YES
 YES
 NO
 NO
Can you walk without assistance?
If you cannot walk without assistance, can you walk if assistance
is provided?
 YES
 NO
Can you hear a fire alarm?
 YES
 YES
 NO
 NO
Can you maneuver stairs without assistance?
If you cannot maneuver stairs without assistance, can you maneuver
stairs if assistance is provided?
 YES
 NO
Do you need to be carried?
 YES
 NO
Do you need assistance exiting a building?
IF YES, PLEASE COMPLETE BELOW:
YOUR SUGGESTION:
 YES
 NO
Do you have seizures? If yes, what type?
Give specific Instructions on seizure first aid request:
____________________________________________________________________________
 YES
 NO
Do you have a health condition that requires ASU personnel to
have special instructions or prior knowledge of condition?
If yes, give specific instructions and other useful information________________________
____________________________________________________________________________
____________________________________________________________________________
Attach brochures, flyers and other relevant printed information relative to your condition.
Student’s Name
Local Address
Emergency contact person and phone number
Other emergency or medical information
Local physician and phone number
Please give Disability Services a copy of your schedule each semester if assistance is
required to help you to exit a building during an emergency.
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AUTHORIZATION TO RELEASE MEDICAL
OR OTHER CONFIDENTIAL INFORMATION
Please release the following confidential records:
 Documentation of disability
 Medical Information
 Psychological or vocational assessment and treatment
 Educational Information
 Other
FOR:
(Name of Student)
I understand that I may revoke this consent to release information at any time;
however, I also understand that any release which has been made prior to my
revocation and which was made based upon this authorization shall not constitute a
breach of my right to confidentiality.
(Student's Signature)
(Date)
(Witness' Signature)
(Date)
READ THE INFORMATION IN THE BOX BELOW AND INITIAL ___________
Arkansas State University has adopted an internal grievance procedure providing for prompt and
equitable resolution of complaints alleging any action prohibited by the U.S. Department of Justice
regulations while implementing Title II of the Americans with Disabilities Act. Title II states, in part,
that “no otherwise qualified disabled individual shall, solely due to such disability, be excluded from
the participation in, be denied the benefits for, or be subjected to discrimination” in programs or
activities sponsored by a public entity.
Complaints should be addressed to Dr. Jenifer Rice-Mason, Coordinator of ADA and 504
compliance efforts for students.
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